Introduction: Ensuring universal access to primary health care (PHC) is a key component of the Ethiopian nationalhealth policy. The policy also emphasises promoting and enhancing national self-reliance in health development bymobilizing and efficiently utilizing resources including community participation. To this end, the government introducedthe accelerated expansion of the PHC strategy through a comprehensive health extension programme (HEP). HEP is afamily and community-based health care delivery system institutionalised at health post level which combines carefullyselected high impact promotive, preventive and basic curative interventions. All HEP interventions are promotive and preventive except the malaria intervention which, in addition, incorporates a curative service. In the country, malaria is a leading disease. Unlike most Sub-Saharan African countries where P. falciparum accounts for almost all malaria infections, in Ethiopia both P. falciparum and P. vivax are co-dominant. Considering this peculiar epidemiological nature, the national guideline recommends alternative diagnosis and treatment strategies. Rationale: The lack of adequate resources and the efficiency with which available resources are being utilised are the main challenges in any health care setting. Therefore, if the HEP which consumes consideral amount of resource desires to reach its intended goal, monitoring and improving its efficiency is of great public heath importance. HEP has been successful in improving access to PHC including the malaria diagnosis and treatment service. Though this is a crucial measure, its quality ought to be considered. For the malaria curative service, studying the cost-effectiveness of the available strategy and patients’ adherence to the treatment regimen can be considered as proxy measures of quality for which local evidence is lacking. However, none of the existing studies in this field of research has addressed the Ethiopian malaria epidemiological context and its diagnosis and treatment guideline. In Tigray, for more than two decades, access to malaria early diagnosis and prompt treatment was facilitated by volunteer community healthworkers (CHWs). However, with the introduction of artemether-lumefantrine (AL) the service was compromised mainly for reasons of cost, safety and logistic. Therefore, it was important to explore the feasibility and the impact of community deployment of AL with rapid diagnostic tests (RDTs). The aim: to explore the overall performance of HEP and particularly the access to and quality of malaria early diagnosis and prompt treatment in the Tigray region of Ethiopia. Methods: Different study designs and populations were used for each of the four specific objectives. Data envelop analysis (DEA) was applied to assess the HEP efficiency. For this, register data for the output variables and primary data for the input and the environmental factors were collected. A health provider perspective cost-effectiveness analysis was used to determine which among the currently available diagnostic and treatment strategies is best for the country. Effectiveness data were generated from a stratified cross-sectional survey and secondary data were used to calculate the cost. For measuring adherence to the six-dose AL regimen, an assessment questionnaire and pill count was employed at patients´ home. To determine whether deploying AL with RDT at community level was feasible and effective, a number of designs were used: longitudinal follow-up, cross-sectional surveys, cost analysis, verbal autopsyquestionnaires and focal group discussions. Main findings: More than three-quarters of the health posts were found to be technically inefficient with an average score of 42%, which implies potentially they could improve their efficiency by 58%. Scale of operation was not a cause of inefficiency. None of the considered environmental factors was associated with efficiency. The Parascreen-based strategy (multispecies RDT-BS) was found to be the most cost-effective strategy, which allowed treating correctly an additional 65% of patients with less cost than the paracheck-BS. Presumptive-BS was highly dominated. Among P.falciparum positive patients to whom AL was prescribed, more than a quarter did not finish their treatment. The main reasons for interrupting the dose were ‘too many tablets’ and ‘felt better before finishing the dose’. The ownership of aradio, the belief that malaria cannot be treated traditionally and a delay of more than one day in seeking treatment after the onset of fever were significantly associated with being adherent. Deploying AL with RDT at community level was demonstrated to be effective and feasible. In the intervention district, almost 60% of suspected cases were managed by CHWs. Malaria transmission was lower at least threefold and malaria mortality risk by around 40% compared to the control district. The use of RDTs reduced cost and possibly the risk of drug resistance development. Conclusion: Though improving access to health care is important, it should be considered a means, not an end. Themore accessible a system is the more people could utilise it to improve their health. Thus, ensuring the access obtainedthrough HEP is maintained, its quality is improved and efficiently utilised to its optimal productivity level is a necessarytask. The DEA study revealed a high level of inefficiency where majority of the health posts needed improvement.This thesis also found parascreen-BS to be the most cost-effective strategy and that there is no epidemiological andeconomical contextual justification to keep both, the presumptive-BS and the RDT-BS specific only to P.falciparum.The high poor adherence levels raises great concern as it leads to recurrent malaria attacks of the patient, speed upthe development and spread of drug resistance strains and reduces the effect of the drug on the transmission. Therefore,providing effective drug alone is not sufficient; assessing and monitoring adherence to the treatment is by faressential. Deployment of AL with RDT through a community-based service has shown an enormous impact in termsof cost, transmission, morbidity and mortality. However, it is worth noting that this results came from an area wherea community-based service has been involved in the PHC system for more than three decades.

Magister Public Health - MPH / Ethiopia‟s health extension programme (HEP), which aims to improve access to and extend the coverage of health services in the country, makes use of the „model families‟ approach as a strategy for diffusing desirable health practices in the community. The approach, which emphasises prevention and health promotion, assumes that through training and accreditation „model families‟ will be able to set an example and encourage communities to embrace healthy lifestyles. However, the programme‟s implementation is not progressing at the pace originally envisaged. In addition, factors influencing the implementation of the „model families‟ approach have not, to date, been explored adequately. Thus, the aim of this study is to investigate the factors hindering or enabling the implementation of the „model families‟ approach as a strategy for improving primary health care (PHC) services in Yelmana-Denssa District (YDD).

Early diagnosis and prompt treatment is one of the malaria control strategies used to minimize malaria morbidity and mortality. One of the mechanisms to implement early diagnosis and prompt treatment is community access to diagnostic services and effective antimalarial drugs. However, in Ethiopia the health system is underdeveloped and much of the rural population has limited access to modern health services. Therefore, the Ethiopian government introduced the Health Extension Programme(HEP) which is a community-based health care delivery system aimed at accessing essential health services through its health extension workers (HEWs). Involvement of the HEWs in prescribing and dispensing antimalarial drugs is shown to have improved community access to antimalarial drugs. However, there is insufficient knowledge of HEWs compliance to malaria treatment guidelines and patient adherence of patients treated by HEWs. The objectives of this study has been to describe the HEWs practice in malaria treatment, to evaluate adherence of patients to antimalarial drugs, to explore the factors influencing the HEWs malaria treatment practice and patient adherence, and to develop the guidelines to support the HEWs in malaria treatment practice. A qualitative study design was used to study the HEWs practice in malaria treatment along with patient adherence. Data were collected using in-depth face-to-face interviews, focus group discussion and patient medical record review and were analysed according to Tesch’s steps. The study revealed that the HEWs adequately comply with malaria treatment guidelines during diagnosis of malaria, as well as during the prescribing and dispensing of antimalarial drugs. However, there are some factors influencing the performance of HEWs. These are: shortage of diagnostic kit/RDT, shortage of antimalarial drugs, patient pressure to obtain coartem, work load, and community beliefs with regard to antimalarial drugs effectiveness. This study also revealed that the HEWs follow up after treatment of patients and good community support systems improved patient adherence to antimalarial drug use. Factors negatively influencing patient adherence were identified to include: forgetfulness, fear of shortage of drugs, adverse drug effects, duration of treatment, rapid relief of malaria symptoms and inadequate awareness of the consequence of incomplete dosage. Guidelines were developed to support the HEWs in malaria treatment practice with the aim to improve patient adherence to antimalarial drugs / Health Studies / D. Litt. et Phil. (Health Studies)

Early diagnosis and prompt treatment is one of the malaria control strategies used to minimize malaria morbidity and mortality. One of the mechanisms to implement early diagnosis and prompt treatment is community access to diagnostic services and effective antimalarial drugs. However, in Ethiopia the health system is underdeveloped and much of the rural population has limited access to modern health services. Therefore, the Ethiopian government introduced the Health Extension Programme(HEP) which is a community-based health care delivery system aimed at accessing essential health services through its health extension workers (HEWs). Involvement of the HEWs in prescribing and dispensing antimalarial drugs is shown to have improved community access to antimalarial drugs. However, there is insufficient knowledge of HEWs compliance to malaria treatment guidelines and patient adherence of patients treated by HEWs. The objectives of this study has been to describe the HEWs practice in malaria treatment, to evaluate adherence of patients to antimalarial drugs, to explore the factors influencing the HEWs malaria treatment practice and patient adherence, and to develop the guidelines to support the HEWs in malaria treatment practice. A qualitative study design was used to study the HEWs practice in malaria treatment along with patient adherence. Data were collected using in-depth face-to-face interviews, focus group discussion and patient medical record review and were analysed according to Tesch’s steps. The study revealed that the HEWs adequately comply with malaria treatment guidelines during diagnosis of malaria, as well as during the prescribing and dispensing of antimalarial drugs. However, there are some factors influencing the performance of HEWs. These are: shortage of diagnostic kit/RDT, shortage of antimalarial drugs, patient pressure to obtain coartem, work load, and community beliefs with regard to antimalarial drugs effectiveness. This study also revealed that the HEWs follow up after treatment of patients and good community support systems improved patient adherence to antimalarial drug use. Factors negatively influencing patient adherence were identified to include: forgetfulness, fear of shortage of drugs, adverse drug effects, duration of treatment, rapid relief of malaria symptoms and inadequate awareness of the consequence of incomplete dosage. Guidelines were developed to support the HEWs in malaria treatment practice with the aim to improve patient adherence to antimalarial drugs / Health Studies / D. Litt. et Phil. (Health Studies)